MEDICARE: EDGAR J EVANGELISTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084D0003X	Diagnostic Neuroimaging (Psychiatry & Neurology) Physician	12377	NV
2	2084N0400X	Neurology Physician	12377	NV
3	2084N0600X	Clinical Neurophysiology Physician	12377	NV

General Provider Information

NPI Number	:	1669693081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDGAR J EVANGELISTA MD

Provider Business Mailing Address
First Line	:	1452 W HORIZON RIDGE PKWY # 566
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89012-4422
Country	:	US
Telephone Number	:	702-800-7831
Fax Number	:	877-409-2014

Provider Business Practice Location Address
First Line	:	2110 E FLAMINGO RD STE 201
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5192
Country	:	US
Telephone Number	:	702-800-7831
Fax Number	:	877-409-2014

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	05/22/2024

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